What is the diagnosis for a patient with chills, right chest pain, back pain upon coughing, and nasal congestion, but no fever?

Diagnosis: Acute Viral Upper Respiratory Tract Infection (Common Cold) with Possible Acute Bronchitis

This patient most likely has an acute viral upper respiratory tract infection (common cold), given the nasal congestion, chills, and cough with pleuritic chest/back pain, particularly in the absence of fever. 1

Clinical Reasoning

The symptom constellation points strongly toward a viral URTI rather than pneumonia or other serious pathology:

• Nasal congestion is the hallmark of the common cold, which is characterized by nasal symptoms with or without fever, throat irritation, and cough 1
• The absence of fever significantly reduces the likelihood of pneumonia - the European Respiratory Society guidelines specify that pneumonia should be suspected when there is acute cough PLUS fever >4 days, new focal chest signs, dyspnea, or tachypnea 1
• Pleuritic chest and back pain with coughing is common in acute bronchitis/tracheobronchitis and does not necessarily indicate pneumonia, especially without fever or focal findings 1
• Chills without documented fever can occur with viral infections and do not mandate investigation for bacterial pneumonia 1

Key Diagnostic Considerations

You must differentiate this from pneumonia, which would fundamentally change management:

• The presence of nasal congestion actually argues AGAINST pneumonia as the primary diagnosis - the European Respiratory Society notes that "fever, absence of URTI symptoms, dyspnea/tachypnea and abnormal chest signs" are the typical combination suggesting pneumonia 1
• A chest radiograph is indicated ONLY if you suspect pneumonia based on: acute cough PLUS one of the following: new focal chest signs on examination, dyspnea, tachypnea, or fever >4 days 1
• Without these findings, chest radiography is neither feasible nor cost-effective, as only 5-10% of patients with acute cough have pneumonia 1

When to Obtain Chest Radiograph

Obtain a chest X-ray if the patient develops:

• Fever persisting >4 days 1
• New focal chest signs on auscultation (crackles, bronchial breathing, dullness to percussion) 1
• Dyspnea or tachypnea 1
• Hemoptysis 1

Management Approach

Antibiotics are NOT indicated - this is almost certainly a self-limited viral illness 1, 2

Symptomatic treatment options include:

• First-generation antihistamine/decongestant combination for nasal congestion and cough 1
• Naproxen for chest wall pain 1
• Dextromethorphan 60mg for cough suppression (higher than typical OTC dosing) 1
• Simple remedies like honey and lemon 1

Critical Pitfalls to Avoid

• Do not diagnose acute bronchitis unless you have ruled out the common cold first - the definitions overlap significantly, and "acute bronchitis" implies a bacterial cause to many patients, leading to inappropriate antibiotic prescribing in 65-80% of cases 1
• Do not assume pleuritic chest pain means pneumonia - chest wall pain from coughing is extremely common in viral URTIs 1
• Do not order a chest X-ray based solely on chest pain and cough without fever or focal findings - this leads to unnecessary radiation exposure and cost 1
• Reassess if symptoms worsen or persist beyond 3 weeks, as this may indicate complications or an alternative diagnosis such as asthma, pertussis, or atypical pneumonia 1, 2